ESC 2015 London Accumulating Clinical data on PCSK9 Inhibition: Key Lessons and Challenges Paul M Ridker, MD, MPH Eugene Braunwald Professor of Medicine Harvard Medical School Director, Center for Cardiovascular Disease Prevention Brigham and Women s Hospital, Boston MA
1961 Framingham Heart Study: factors of risk 1972 Bill Friedewald, Bob Levy, Don Fredrickson Formula to estimate plasma LDL 1973 Michael Brown and Joseph Goldstein Identification of LDLr mutations in FH 1976 Akiro Endo identification of mevastatin as an inhibitor of HMG-CoA (Sankyo) 1994 Scandinavian Simvastatin Survival Study 2003 Abifabel M et al, Gain of function mutation in PCSK9 as a cause of FH 2005 Cohen et al, loss of function PCSK9 mutation 2008 JUPITER: Event reduction and safety driving LDL from 100mg/dL to below 50 mg/dl 2013 Introduction of three new classes of therapy for aggressive LDL reduction 2015 Initial approval of first PCSK9 inhibitors
Recurrent Myocardial Infarction or Coronary Death Ridker et al NEJM 2005;352:20-28. Statin Therapy and LDL Cholesterol: The Primary Pharmacologic Target for Cardiovascular Event Reduction 1. LDL-C is a strong, independent predictor of future CV events 2. Statins Lower LDL-C 3. The level of LDL-C achieved after starting statin therapy predicts recurrent event rates ( lower is better ) 0.00 0.02 0.04 0.06 0.08 0.10 LDLC>70 mg/dl (>1.8 mmol/l) Residual Risk LDLC<70 mg/dl 0.0 0.5 1.0 1.5 2.0 2.5
JUPITER Outcomes bases on Achieving LDLC < 50 mg/dl Cumulative Incidence Ridker et al Lancet 2009 0.00 0.02 0.04 0.06 0.08 0 1 2 3 4 Placebo LDL > 50 mg/dl Rosuvastatin (>1.3 mmol/l) LDL<50 mg/dl Rosuvastatin (<1.3 mmol/l) Follow-up (years)
JUPITER Predicted vs Observed Benefit Based on Percent LDL Reduction Relative Risk Reduction (%) 60 50 JUPITER 40 AF/TEX ASCOT CARDS 4S 30 20 LIPID WOSCOPS HPS CARE ALERT LIPS SPARCL PROSPER 10 ASPEN 0 0 10 20 30 40 50 60 % Reduction in LDL-C
JUPITER Event Reduction At All Levels of Baseline LDLC Baseline LDLC Levels N LDLC <100 mg/dl (2.6 mmol/l) 6,269 LDLC <90 mg/dl (2.3 mmol/l) LDLC <80 mg/dl (2.0 mmol/l) LDLC <70 mg/dl (1.8 mmol/l) LDLC <60 mg/dl (1.5 mmol/l) 3,687 2,033 1,022 511 On Treatment LDL < 50 mg/dl (<1.3 mmol/l) 25% On Treatment LDL < 25 mg/dl (<0.64 mmol/l) All Participants 17,802 0.20 0.5 1.0 2.0 4.0 Rosuvastatin Better Rosuvastatin Worse 6
JUPITER Safety of Lowering LDL-C to Below 50 mg/dl Hsia et al, JACC ;57:1666-75 LDLC LDLC P >50mg/dL < 50mg/dL (>1.3 mmol/l) (<1.3 mmol/l) Myalgia 4.0 3.5 0.49 Gastrointestinal 14.0 14.4 0.32 Respiratory 8.0 8.9 0.08 CNS 8.3 8.3 0.60 Memory Loss 0.2 0.1 0.04 Renal 4.3 4.8 0.30 Cancer 1.5 1.4 0.36 Diabetes 1.2 1.6 0.70 ALT>3x ULN 0.7 0.7 0.78 CK>10x ULN 0.01 0.01 0.99 Proteinuria 2.5 2.6 0.29
Why Are Additional Agents Beyond Statins Needed? Residual risk is substantial Statin intolerance is a real issue in clinical practice By looking only at average response rates in our meta-analyses and guidelines, we have systematically ignored the wide variation that exists in individual lipid response to statin therapy. This wide variation in response impacts directly on clinical outcomes, yet has been at least partially forgotten in the US based guidelines that have moved away from cholesterol targets. We need to consider individual statin response, not only population statin response.
What Pharmacologic Strategies for LDL Reduction Beyond Statins are Emerging? Cholesterol Absorption Inhibitor Ezetimibe CETP Inhibitors Torcetrapib, Dalcetrapib, Anacetrapib, Evacetrapib Microsomal Triglyceride Transfer Protein (MTP) Inhibition Lomitapide Anti-Sense Oligonucleotide (ASO) binding to APO B coding RNA Mipomersen PCSK9 inhibitors monoclonal antibodies Alirocumab Bococizumab Evolocumab PCSK9 inhibitors other modalities Small molecule inhibitors Adnectins Therapeutic RNAi ETC-1002 (dual modulator ATP-citrate lyase/amp-activated protein kinase) MBX-8025 (PPAR-d agonist)
Monoclonal Antibodies to PCSK9 and Recycling of the LDL Receptor - Phase II Effective as monotherapy Koren Lancet 2012;380:1995-06 Sullivan JAMA 2012;308:2497-06 Effective as statin add-on Stein Lancet 2012;380:29-36 Stein NEJM 2012;366:1108-18 McKenney JACC 2012;59:1108-18 Guigliano Lancet 2012;380:2007-17 Roth NEJM 2012;367:1891-900 Blom NEJM 2014;370:1809-19 Effective in statin intolerance Stroes JACC 2014;63:2541-8 Effective in heterozygous FH (reduced LDLr activity) Raal Circulation 2012;126:2408-17 Effective in homozygous FH (LDLr defective) Stein Circulation 2013;128:2113-20
Monoclonal Antibodies to PCSK9 and Recycling of the LDL Receptor Phase III Evolocumab (Amgen) Fourier NCT 01764633 Alirocumab (Sanofi/Regeneron) ODYSSEY NCT 01663402 Bococizumab (Pfizer) SPIRE I, SPIRE II NCT 01975376 NCT 01975389 > 70,000 + patients worldwide
Sabatine et al for the OSLER Investigators NEJM March 15, 2015 (evolocumab) Robinson et al for the ODYSSEY Investigators NEJM March 15, 2015 (alirocumab)
Gugliano, RP, Sabatine, MS. JACC 2015;24:2638-51
Total Events (N) 53 60 Gugliano, RP, Sabatine, MS. JACC 2015;24:2638-51
High Dose Statins (%) 47 % 27% Gugliano, RP, Sabatine, MS. JACC 2015;24:2638-51
Are There Early Side Effect Signals? Adverse Event Agent Drug Placebo Injection Site Reaction Evolocumab 4.3 NA Alirocumab 5.9 4.2 Arthralgia or Myalgia Evolocumab 4.6 3.2 Alirocumab 5.4 2.9 Neurocognitive Events Evolocumab 0.9 0.3 Alirocumab 1.2 0.5 Ophthamalogic Events Alirocumab 2.9 1.9 Fatigue Evolocumab 2.8 1.0 Headache Evolocumab 3.6 2.1 Sabatine et al for the OSLER Investigators NEJM March 15, 2015 Robinson et al for the ODYSSEY Investigators NEJM March 15, 2015
PCSK9 Inhibitors: From Target Discovery to Phase III in 10 Years PCSK9 (NARC-1) discovered PCSK9 GOF mutations associated with ADH* PCSK9 LOF Mutations found with 28% LDL-C and 88% CHD risk Humans null for PCSK9 have LDL-C ~15 mg/dl Plasma PCSK9 binds to LDL-R First Patients with FH / non-fh treated with PCSK9i mab 1 st FDA / EMEA PCSK9i filing 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Adenoviral expression in mice PCSK9 KO mouse LDL-C First subject treated with PCSK9 mab LDL-C in mice and non-human primates treated with anti-pcsk9 mab First publication POC in patients
Major CV Outcome Trials of PCSK9 inhibition Lipid Lowering PROFICIO Evolocumab ODYSSEY Alirocumab SPIRE Bococizumab HeFH HoFH CVD / CVD RE Statin Intolerance and/or Monotherapy Imaging CV Outcomes Fourier Outcomes 1 2 Prior MI / Post ACS Prior Stroke PVD Diabetes without CHD CKD without CHD Statin Intolerance?
PCSK9 Inhibitors Major CV Outcome Trials of PCSK9 inhibition: timelines 2011 2012 2013 2014 2015 2016 2017 2018 Pfizer Bococizumab Lipid Lowering Studies CVOT: SPIRE-1 LDL-C 70 100 mg/dl CVOT: SPIRE-2 with LDL-C >100 mg/dl Sanofi/Regen Alirocumab Lipid Lowering Studies CVOT: ODYSSEY Outcomes Amgen Evolocumab Lipid Lowering CVOT: FOURIER
Why Completing the Phase III Trials Is Crucial Is aggressive LDL-C reduction with PCSK9 inhibition safe and clinically effective? Can we lower LDL-C too far? What is the evidence for LDL-C reduction even when LDL-C levels are low? Is LDL lowering without inflammation inhibition effective? Will our patients live longer and more productive lives?
We are exceptionally lucky to be in era with ongoing direct tests of both the LDL hypothesis and the inflammation hypothesis Agent Event Reduction? LDL-Lowering? CRP-Lowering? Statins Yes Yes Yes Ezetimibe + Statin Yes Yes Yes Evolocumab?? Yes No Alirocumab?? Yes No Bococizumab?? Yes No Canakinumab?? No Yes Low Dose MTX?? No Yes